Application3aoc)
0 ED-O BUILDING PERMIT
APPLICATION
Development Services
Building Division
121 5th Ave N / Edmonds, WA 98020
�° c • 1 ' `3 425.771.0220
For handouts, submittal requirements, permit status and inspection
scheduling information go to: Eirt�} Iltivwtiv, edmori{isw:�.1;
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
job Site Address: % 1 12) ko
Parcel:
Lot /Unit/Suite #: Subdivision:
PROPERTY OWNER:
Name: Se-ke_c - R Wle-s (ytG -
Mailing Address: [(AS
31 r i • W "0
city/state/zip: [ S4►nV%W0ad U)VW CITO'3 -' _
Phone #: qZS' tq?.' (ob qN
Email: r • C-o
OWNER INSTALLATION: *If yes, read and sign*
Will work be performed by the property owner? ❑ Yes ❑ No
I own, reside in, or will reside in the completed structure.
This installation is being made on property that I own which is
not intended for sale, lease, rent, or exchange according to
RCW 18.27.090.
Owner Signature:
APPLICANT / CONTACT INFORMATION:
Name of Applicant: K-&%AtQ1 NN%6AOES,Se[C[k ROWL(IS,IIn
Mailing Address: IUS31 ilt'' C• LU. �-1,b_F_
City/State/Zip: (u%Ivxk^'ood- 001-
Phone #: 2• I(o0
E-mail: OQROOV_ • Co 'A
GENERAL CONTRACTOR: (If different from applicant)
General Contractor:IL-1c.
Mailing Address: i I�V�- 0+
City/State/Zip: W "' 9'03 - -
Phone #: --f-Z • (a G YY
E-mail: 40 V" t
WA STATE CONTRACTOR L & I # (CCB) & EXPIRATION DATE:
�ELECHS'l1oK11�3 12.SI- !4
CITY OF EDMONDS BUSINESS LICENSE #: �Q ' 02 (eSel I
Permit #: 8 LP) ;? D,;L O _ 0 o�
TYPE OF
❑ Accessory Structure/
Detached Garage
.- Details
❑ Addition
❑ Demolition
❑ Mechanical
Klew Single Family / Duplex
❑ Plumbing
❑ Fire Sprinkler
❑ New Commercial/ Mixed Use
❑ Remodel
I ❑ Re -Roof
❑ Signs
❑ Tank
❑ Tenant Improvement
❑ Other
Remodel Permit fees are based on:
The value of the work performed. Indicate the value (rounded to
the nearest dollar) of all equipment, materials, labor, overhead,
and the profit for the work indicated on this application.
Valuation:
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION
Basement sq ft: Finished ❑ Unfinished ❑
1st Floor, sq ft:
! Li
2nd Floor, sq ft:
1S3
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio: SOS
C16Cher sq ft:
PROJECT•
Wes% ���--
I certify that the information I have provided on this form/application is true,
correct and complete, and that I am the property owner or duly authorized
agent of the property owner to submit a permit application to the City of
Edmonds. II
Print Name: 1 ►�'l
Signature: OF,_��^� ate !U-ZB'•Iq
rs
GENERAL• DATA
Occupancy Group(s): Occupant Load(s):
Type(s) of Construction: Fire Sprinklers: Yes No El
-
WA STATE ENERGY CODE: If your project affects the building envelope,
mechanical systems, and/or lighting, you must complete the
appropriate WSEC forms.
DEFERRED SUBMITTALS: All commercial building permits that will require
associated plumbing, mechanical, fire sprinkler, and/or fire alarm
permits are applied for separately.
TI / CHANGE OF USE / NEW BLDG: Include TRAFFIC IMPACT worksheet
EQUIPMENTMECHANICAL •
BTUs Gas / Elec / Other City
A/C Unit/Compressor
Air Handler/VAV
Boiler
Dryer Duct
Exhaust Fans
G
Fireplace
l
Furnace
Heat Pump Unit
Hydronic Heating
Roof Top Unit (Provide eleva-
tions if a Commercial Bldg)
Other:
COUNTSPLUMBING FIXTURE or re -piped)
City QtY
Clothes Washer
I
Tub/ Showers
u
Dishwasher
`
Backflow Device (RPBA, DCDA, AVB)
Drinking Fountain
Pressure Reduction/ Regulator Valve
Floor Drain/Sink
Refrigerator Water Supply
I
Hose Bibs
Water Heater-Tankless?3or N
Hydronic Heat
Water Service Line
1
Sinks
Other:
Toilets
3
Other:
GAS/FUEL CONNECTION COUNTS (New, Relocated or re -piped)
BTUs Qty BTUs City
A/C Unit
Outdoor BBQ/ Fire pit
Boiler
Stove/Range/Oven
71
Dryer
i Water Heater
I
1
Fireplace/ Insert
Other:
Furnace l Other:
COUNTSMEDICAL GAS, AIR VACUUM
Relocated or ..••
City
Qty
Carbon Dioxide
Nitrous Oxide
Helium
Oxygen
Medical Air
Other:
Medical - Surgical Vacuum Other:
DEMOLITION
Type of structure to be demolished:
Square footage of structure to be demolished:
AHERA Survey done? Y / N
PSCAA Case #:
Critical Areas Determination:
Study Required ❑ Conditional Waiver ❑ Waiver ❑
Fill in Place ❑ Fill Material:
Removal ❑ Size of Tank (Gallons)
Critical Areas Determination:
Study Required ❑ Conditional Waiver ❑ Waiver ❑
.DEXCAVATE
Grading: Cut �� cubic yards
Fill U0 cubic yards
Cut / Fill in Critical Area: Yes ❑ No K
GENERALPROVISIONS
APPLICATIONS: Applications are valid for a maximum of 1 year.
ESLHA Applications, 2 years.
LICENSING: All contractors and subcontractors are required to be licensed
with Washington State Department of Labor & Industries and have a
current City of Edmonds Business License.